Critical care explorations最新文献

This study aimed to determine if extended infusion (EI; over > 3 hr) beta-lactam therapy increased IV access requirements compared with traditional dosing (TD; over 30 min). Eighty-six adult ICU patients treated with TD anti-pseudomonal beta-lactams who underwent therapeutic drug monitoring (TDM) were included. Patients who transitioned from TD to EI after TDM (EI group) were matched 1:1 to patients who remained on TD. In the primary analysis, the median (interquartile range) total number of lumens in the 24 hours before TDM compared with the 48 hours after TDM were similar between groups (pre: TD 3 [2-5] vs. EI 4 [3-5]; p = 0.22 and post: TD 3 [2-4] vs. EI 4 [3-5]; p = 0.05). Delivery of beta-lactams via EI was not associated with a need for more IV access. Practical challenges such as access should not limit use of EI beta-lactams when indicated.

Pneumocystis jirovecii pneumonia (PCP) is a life-threatening opportunistic infection increasingly recognized among non-HIV immunocompromised patients. In severe cases progressing to acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV-ECMO) may serve as a rescue therapy. We conducted a retrospective multicenter review of 10 adult patients with proven or probable PCP who received VV-ECMO between 2017 and 2024. Seven of 10 patients survived to discharge, including all three HIV-positive patients and 4 of 7 non-HIV immunocompromised patients. The mean Respiratory ECMO Survival Prediction Score was -1.5, corresponding to a predicted survival of 33-57%. Multiorgan dysfunction was common, including renal failure requiring dialysis in 6 of 10 patients, need for neuromuscular blockade in 8 of 10, and pulmonary vasodilator use in 8 of 10. Despite high acuity and prolonged ECMO support, outcomes were favorable. These findings suggest that VV-ECMO may be a viable salvage therapy for select patients with severe PCP, including those without HIV.

Pneumocystis jirovecii pneumonia (PCP) is a life-threatening opportunistic infection increasingly recognized among non-HIV immunocompromised patients. In severe cases progressing to acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV-ECMO) may serve as a rescue therapy. We conducted a retrospective multicenter review of 10 adult patients with proven or probable PCP who received VV-ECMO between 2017 and 2024. Seven of 10 patients survived to discharge, including all three HIV-positive patients and 4 of 7 non-HIV immunocompromised patients. The mean Respiratory ECMO Survival Prediction Score was -1.5, corresponding to a predicted survival of 33-57%. Multiorgan dysfunction was common, including renal failure requiring dialysis in 6 of 10 patients, need for neuromuscular blockade in 8 of 10, and pulmonary vasodilator use in 8 of 10. Despite high acuity and prolonged ECMO support, outcomes were favorable. These findings suggest that VV-ECMO may be a viable salvage therapy for select patients with severe PCP, including those without HIV.

This study aimed to determine if extended infusion (EI; over > 3 hr) beta-lactam therapy increased IV access requirements compared with traditional dosing (TD; over 30 min). Eighty-six adult ICU patients treated with TD anti-pseudomonal beta-lactams who underwent therapeutic drug monitoring (TDM) were included. Patients who transitioned from TD to EI after TDM (EI group) were matched 1:1 to patients who remained on TD. In the primary analysis, the median (interquartile range) total number of lumens in the 24 hours before TDM compared with the 48 hours after TDM were similar between groups (pre: TD 3 [2-5] vs. EI 4 [3-5]; p = 0.22 and post: TD 3 [2-4] vs. EI 4 [3-5]; p = 0.05). Delivery of beta-lactams via EI was not associated with a need for more IV access. Practical challenges such as access should not limit use of EI beta-lactams when indicated.

Importance and objectives: Inhaled volatile anesthetics are employed as rescue therapy in near-fatal asthma, despite limited evidence. This study aims to describe the characteristics, management, and outcomes of mechanically ventilated adult patients with near-fatal asthma, stratified by the use of volatile anesthetic therapy.

Design: Retrospective single-center observational cohort study.

Setting: Tertiary critical care and extracorporeal membrane oxygenation (ECMO) unit.

Participants: Adults 16 years old or older receiving mechanical ventilation (MV) for greater than or equal to 24 hours and/or ECMO between January 2016 and August 2023 for near-fatal asthma.

Main outcomes and measures: We recorded demographics, disease severity tidal volumes, and ventilator settings, by treatment over the first 100 hours. Outcomes were duration of ECMO and MV, ICU length of stay, 90-day mortality, and adverse drug reaction.

Results: Sixty-two patients were included (62.9% female), with a median (interquartile range [IQR]) age of 45 years (29-51 yr). Median (IQR) pH 7.13 (6.93-7.23), Paco2 12.9 kPa (8.7-16.2 kPa), and tidal volume 178 mL (50-300 mL). Most patients received IV bronchodilators and 32 (51.6%) required ECMO. Thirty-eight patients (61.3%) were treated with volatile anesthetics. Volatile patients had worse ventilation and blood gas parameters before treatment, more barotrauma, and were more likely to be receiving ECMO. Despite this, improvements in tidal volume occurred in the volatile group (mean increase, 204 mL [83.9%]; 95% CI, 110-298; p < 0.001). Median (IQR) duration of MV and ICU length of stay in volatile and no volatile patients were 10 days (8-16 d) vs. 5 days (3-10 d; p = 0.001) and 15 days (13-20 d) vs. 9 days (7-14 d; p = 0.001), respectively. ICU and 90-day mortality in volatile and no volatile patients were 5.3% vs. 4.2%.

Conclusions and relevance: The use of inhaled volatile anesthetics for near-fatal asthma, including during ECMO, appears to be feasible and safe, and with favorable clinical outcomes; however, no conclusions regarding efficacy can be directly inferred.

Context: Direct preclinical lipopolysaccharide acute lung injury (ALI) models are commonly used to study acute respiratory distress syndrome. Differences in lipopolysaccharide delivery methods may impact lung injury severity and reproducibility.

Hypothesis: We hypothesized that the severity and variability of ALI outcomes in mice would differ depending on the technique of lipopolysaccharide administration.

Methods and models: Male and female C57BL/6 mice were administered lipopolysaccharide (2.25 mg/kg) via four methods: 1) intratracheal intubation; 2) intranasal; 3) surgical transtracheal by either needle puncture; or 4) by catheter. ALI severity and variability were assessed at 72 hours post-lipopolysaccharide via histological scoring and bronchoalveolar lavage fluid (BALF) analysis (total protein, cell counts, interleukin-6 [IL-6]). The relative distribution of Evans Blue dye was also assessed for each model (lungs vs. stomach).

Results: Distinct lung injury patterns were observed between the four methods. The transtracheal with catheter method demonstrated significantly greater lung injury scores than the intratracheal intubation and intranasal techniques. Both transtracheal methods produced greater alveolar neutrophil counts, increased proteinaceous debris, fewer hyaline membranes, and lower variability than non-surgical techniques. The transtracheal with catheter method produced higher BALF total cell counts and IL-6 levels than intratracheal intubation. Transtracheal methods also resulted in more localized Evans Blue dye distribution in the lungs. Male mice exhibited more severe lung injury scores and higher BALF protein concentrations than females.

Interpretation and conclusions: This study demonstrates that the choice of technique to administer lipopolysaccharide impacts injury severity, phenotype, and variability. The surgical transtracheal with catheter technique produced the most robust and least variable ALI phenotype; however, this technique is associated with increased procedural complexity. Our results will allow researchers to tailor their model choice to align with their specific study objectives.

Objectives: Intensive care is a critical but resource-intensive component of healthcare. Health economic evaluations, such as cost-effectiveness analyses (CEAs), offer valuable insights for decision-making by weighing the costs and benefits of various healthcare interventions. We aimed to identify and summarize the existing health economic evaluations within intensive care and identify areas for future research.

Data sources: We searched six academic databases to identify full health economic evaluations of ICU interventions published between 1993 and 2023. Databases included: Ovid (MEDLINE, Embase, and evidence based medicine (EBM) Reviews [Health Technology Assessments and National Health Service (NHS) Economic Evaluation Database]), EBSCO (CINAHL and EconLit), and Web of Science.

Study selection: Health economic evaluations of interventions for adult patients in the ICU were included. Economic evaluations include CEAs, cost-utility, cost-benefit, and cost-minimization analyses, while pediatric, animal and weaning center studies were excluded.

Data extraction: Data were extracted by two independent reviewers. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

Data synthesis: We identified 219 relevant studies published between 1993 and 2023, with a significant rise in publications over the last decade. Most studies (97%) had good to excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (more effective and less expensive) to $753,874 per life saved. ICERs for both cost per quality-adjusted life-years and cost per life-year gained ranged from dominant to dominated (more costly and less effective). Three studies (1%) were published in low- and middle-income countries (LMICs) and 58% of studies were modeling studies.

Conclusions: Despite the importance of economic evidence in healthcare decision-making, there is a relative scarcity of cost-effectiveness studies in intensive care compared with other medical fields. Available economic evaluations in intensive care are characterized by significant heterogeneity. The wide range of ICERs for life saved, life-years gained, and quality-adjusted life-years reflects the diversity of ICU patients, interventions, and evaluation methods. Future research in LMICs and increasing trial-based research is recommended.

Importance: Sepsis is a leading cause of morbidity and mortality. Understanding sepsis epidemiology is crucial to enable clinicians to identify patients at highest risk of developing and dying from sepsis.

Objectives: While community-acquired (CA) sepsis has been identified as more common than hospital-acquired (HA) sepsis, HA sepsis has led to increased morbidity and mortality. Few studies, however, have analyzed CA and HA sepsis by site of infection or by patient comorbidities. The aim of this analysis was to describe the epidemiology of patients with CA and HA sepsis diagnosed in Ireland.

Design, setting, and participants: This was a retrospective cohort study. The setting was all Irish acute public hospitals from 2016 to 2022. Data were extracted from the Hospital In-Patient Enquiry (HIPE) system recording all discharges from acute public hospitals, if a sepsis-related diagnostic code was included.

Main outcomes and measures: Univariate and multivariate analysis was conducted to compare CA and HA sepsis events and their association with sepsis-associated mortality.

Results: The number of CA vs. HA sepsis events in the database was 86,011 (85.2%) vs. 14,930 (14.8%). HA sepsis patients were 1.5 times more likely to die in hospital compared with CA. Of diagnoses analyzed, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the strongest risk factor predictive of mortality (odds ratio [OR] = 2.4) followed by cardiac disease (OR, 1.9) and influenza or pneumonia (OR, 1.9). Sepsis patients with a lower socioeconomic status had a 20% higher likelihood of death.

Conclusions and relevance: This analysis highlighted a significant increased risk of sepsis-associated mortality for patients diagnosed with sepsis as a result of a HA infection and key infection types and comorbidities including SARS-CoV-2, influenza or pneumonia, cancer, and cardiac disease.

Objectives: Cardiac mechanical efficiency has been shown to be a predictor of fluid responsiveness (FR) in adults. Our goal was to assess the association between mechanical efficiency as measured by dynamic arterial elastance (Eadyn) and mean arterial pressure (MAP) after fluid bolus in children with MAP less than or equal to 50th percentile for age.

Design: This was a retrospective, observational cohort study.

Setting/patients: This studied IV crystalloid fluid boluses of greater than or equal to 10 mL/kg given to patients less than or equal to 18 years old within the first 72 hours of admission to an academic PICU.

Interventions: None.

Measurements and main results: Eadyn was calculated in 10-second intervals during the 20 minutes pre-bolus. FR was defined as an increase of greater than or equal to 10% in MAP from pre-bolus to the average MAP over 20 minutes post-bolus. Kruskal-Wallis test was used to assess associations. We analyzed 490 fluid boluses given to children with MAP less than or equal to 50th percentile for age across 365 PICU encounters. Pre-bolus Eadyn was not associated with FR (p > 0.1). This lack of association persisted in subgroup analysis among those mechanically ventilated or on vasoactive medication, and in stratification by MAP percentile for age and duration of time in MAP percentile. Additionally, mechanical efficiency was high (Eadyn > 0.7) for most children, even in the lowest MAP percentile for age cohorts.

Conclusions: Further research is needed in children to understand the changing cardiac physiology of children as blood pressure decreases to develop more targeted, age-based shock management strategies.

Presentations of status asthmaticus or severe chronic obstructive pulmonary disease exacerbation can present a formidable challenge to effective invasive ventilation. The optimal ventilation strategy targets low respiratory rates and high inspiratory flow rates to prolong the expiratory time and minimize dynamic hyperinflation. Although the resulting high peak pressures can usually be accommodated by ICU ventilators, some ventilators have a relatively limited peak pressure capacity as determined by the turbine. Here, we describe two cases of severe airflow obstruction where the desired ventilation strategy required a peak pressure over the capacity of the Hamilton T1 transport ventilator. Changing to a pressure regulated strategy, maximizing the driving pressure, and titrating the inspiratory time overcame the limitation. But, this strategy comes at a cost. Clinicians should be made aware of the possibility of a pressure limitation in their ventilator and understand how to adjust their ventilation strategy appropriately during transitions.